Exam II Flashcards by Tanner Watson

Nursing Interventions r/t Chest Tube

Pain Meds
Pulmonary Hygiene (deep breaths, coughs, IS)
Reposition to side-lying if a report of “burning” pain in the chest (chest tube stuck to wall)

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Positioning of the Chest Tube Drainage System

Keep drainage system lower than the pt’s chest
Avoid kinks and dependent loops by keeping chest tube as straight as possible from bed to suction unit
Keep tubing above the drainage system so it does not collect in the tubing

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What does it mean when there is continuous bubbling in the chamber?

NOT OKAY! Air leak possible

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When assessing for an air leak, you must clamp the tubing with your fingers. How long should you clamp for and why?

Clamp for only a few seconds, risk for tension pneumothorax.

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What do you do if the pt’s chest tube dislodges from the patient?

Apply a sterile occlusive dressing
Close dressing on three sides

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What if we think the chest drain tubing is obstructed?

Use the hand-over-hand technique, do not MILK the tubing- risk for increased pressure

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When should you immediately call the Provider and/or Rapid Response?

Tracheal deviation from the midline (tension pneumothorax)
Sudden onset of increased dyspnea
SpO2 <90%
Drainage > 70 mL/hr
If eyelets are visible on chest tube
Dislodgment of chest tube
Disconnection of chest tube from drainage unit
Drainage stops in the first 24 hours (obstruction)

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An alert and oriented patient is admitted to the ED with a GCS of 10. Which finding should the nurse report to the provider immediately?
A. Photophobia with HA
B. New Onset Dizziness
C. Brisk Pupil Response
D. Sudden Drowsiness

D. Sudden Drowsiness (ICP!)

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Pt has blood stain displaying a positive halo sign. What is the priority concern for this patient?
A. Inability to communicate
B. Nutritional Deficit
C. Risk for acquiring infection
D. Risk for VAP

C. Risk for infection (Halo sign= CSF leak…most likely Basilar skull fracture) “If things are flowing out, they can flow in”

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A patient with Myasthenia gravis has flaccid paralysis. A tensilon challenge is performed. Discuss potential results, interpret results, and any complications (and subsequent interventions).

If the paralysis improves with the tensilon test, this is a Myasthenia crisis. We would need to protect the airway by providing O2, possibly intubate or BiPap. Plasmapheresis.
If the paralysis worsens, this is a cholinergic crisis. Manage airway here as well due to the thickened secretions. Give atropine.

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Discuss priority assessment (and interventions) for patient with a C2-C3 SCI.

ABC’s. Preventing a secondary injury (spinal precautions). Neuro assessments. Gathering as much information as possible.

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A patient is in MG cholinergic crisis. What are your concerns and likely intervention?

Respiratory issues, breathing issues. Suction, atropine. Later on- nutrition and speech.

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What are the early manifestations of Multiple Sclerosis?

Visual, sensory, mobility issues.

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Discuss early and late manifestations of ALS.

Early: fatigue, weakness, upper arms, facial weakness

Late: complete paralysis and respiratory decline

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What are the criteria for brain death (in context of organ donation)?

Coma for known cause, Normal body temperature, Normal BP, 2 MD’s perform neuro exam

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What are the indicators for poor prognosis with TBI?

Hypoxia, Fever, Blown/Fixed pupils, Low CPP (<70), 2 point change in GCS, Cushing’s Triad (bradycardia, widened pulse pressure, irregular respirations) –> sign of herniation.

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How do you calculate CPP? What is this? What do the results mean?

MAP (>65) - ICP (10-15)

MAP = [(2 x Diastolic) + Systolic] / 3
Therapeutic CPP = 70 or greater
Brain perfusion! Results less than 70 is an indicator of a poor prognosis, brain is not getting enough oxygen.

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Cushing Triad: What does it mean and what should you do? What is it?

Cushing Triad: Late sign of increased ICP; may very well be death
1. Bradycardia
2. Widened pulse pressure (HTN)
3. Changes in respiration (irregular)

Get help, Code cart, Mannitol, Craniotomy

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A patient with a SCI (long-standing) tells you she thinks something bad is happening. You take VS: BP 210/111, HR 51. Discuss what you do first, second….

Autonomic Dysreflexia
1. Place patient in sitting position
2. Assess for cause (full bladder, UTI, bowel distention/ impaction/ constipation, circumferential compression, temperature change, pain)
3. Get help
4. Nicardipine drip (antihypertensives)

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What are nursing interventions for a patient with increased ICP?

Frequent neuro checks
HOB 30-45 degrees
Diuretics (mannitol)
Strict I/O
Suppress cough, avoid constipation

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What are some causes of secondary TBI?

Ischemia, Inflammation
Excitatory
Bleeding
Hypovolemia/ Hypotension (MAP)
Neurogenic Shock
Hypoxia (PaO2 < 80)
Cerebral edema
Immobilization did not happen (no spinal board used)

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How do you prevent secondary TBI?

Maintain CPP > 70 and MAP > 65
Monitor for increased ICP (changes in LOC, HA) and GCS changes (2 points is bad!)

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Presentation of Subdural hematoma versus Epidural bleed

Epidural: LOC, awake, rapid decline
Subdural: can happen over hours to months

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Priority of care for a patient in myasthenia crisis.

Symptom management
Drug therapy: Cholinesterase inhibitor (Pyridostigmine- take with food!), corticosteroids, IV IgG, and Monoclonal antibodies
Plasmapheresis
Activity-Rest Balance (weakness worsens with activity)
Respiratory: assisted cough, suction, chest physiotherapy, NPPV

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Priorities of care for a patient with GBS? Also, discuss the presentation of GBS (early signs and potential complications)

Ascending paralysis (peaks around 4 weeks), airway management

Admission VS for a brain-injured patient are blood pressure of 128/68, pulse 110, and respirations 26. Which set of VS, if taken 1 hour later, will be of most concern to the nurse? A. BP 154/68, 56 beats/min, 12 breaths/min B. BP 134/72, 90 beats/min, 32 breaths/min C. BP 148/78, 112 beats/min, 28 breaths/min D. BP 110/70, 120 beats/min, 30 breaths/min

A. BP 154/68, 56 beats/min, 12 breaths/min

The nurse has administered the prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? A. Blood pressure B. Oxygen saturation C. Intracranial pressure D. Hemoglobin and hematocrit

C. Intracranial pressure

An unconscious patient has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care? A. Encourage coughing and deep breathing. B. Position the patient with knees and hips flexed. C. Keep the head of the bed elevated to 30 degrees. D. Cluster care to provide rest periods.

C. Keep the head of the bed elevated to 30 degrees.

Which action will the ED nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? A. Coordinate the transfer of the patient to the OR. B. Provide discharge instructions about monitoring neurologic status. C. Transport the patient to radiology for an MRI. D. Arrange to admit the patient to the neurological unit for 24 hours of observation.

B. Provide discharge instructions about monitoring neurologic status.

Which statement by patient who is being discharged from the ED after a concussion indicates a need for intervention by the nurse? A. "I will return if I feel dizzy or nauseated" B. "I am going to drive home and go to bed." C. "I do not even remember being in an accident" D. "I can take Tylenol for my headache."

B. "I am going to drive home and go to bed."

A patient admitted with a diffuse axonal injury has a BP of 106/52 and an ICP of 14. Which action should the nurse take first? A. Document the BP and ICP in the patient's record. B. Report the BP and ICP to the provider. C. Elevate the HOB to 60 degrees. D. Continue to monitor the patient's VS and ICP.

B. Report the BP and ICP to the provider.

After endotracheal suctioning, the nurse notes that the ICP for a patient with a TBI has increased from 14 to 17. Which action should the nurse take first? A. Document the increase in ICP. B. Ensure that the patient's neck is in neutral position. C. Notify the provider about the change in pressure. D. Increase the rate of prescribed Propofol.

B. Ensure that the patient's neck is in neutral position.

After the ED nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? A. 20 yr old whose cranial x-ray shows a linear skull fracture. B. 50 yr old who has an initial GCS of 13. C. 30 yr old who lost consciousness for a few seconds after a fall. D. 40 yr old whose right pupil is 10mm and unresponsive to light.

D. 40 yr old whose right pupil is 10mm and unresponsive to light.

After evacuation of an epidural hematoma, a patient's ICP is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider? A. Pulse of 102 bpm B. Temperature of 101.6 F C. ICP of 15 D. MAP of 90

B. Temperature of 101.6 F

A 68 yr old male patient is brought to the ED by ambulance after falling on the bathroom floor and losing consciousness. Which action will the nurse take first? A. Check oxygen saturation. B. Assess pupil reaction to light. C. Palpate the head for injuries. D. Verify GCS score.

A. Check oxygen saturation.

While admitting a 42 yr old patient with a possible brain injury after a car accident to the ED, the nurse obtains the following information. Which finding is most important to report to the provider? A. The pt takes warfarin (Coumadin) daily. B. The pt's BP is 162/94. C. The pt is unable to remember the accident. D. The pt complains of a dull HA.

A. The pt takes warfarin (Coumadin) daily.

Which action will the nurse include in the plan of care for a patient who is experiencing pain from trigeminal neuralgia? A. Assess fluid and dietary intake. B. Apply ice packs for 20 minutes. C. Teach facial relaxation techniques. D. Spend time talking with the patient.

A. Assess fluid and dietary intake.

Which assessment data for a patient with Guillian-Barre will require the nurse's most immediate action? A. Pt's sacral area skin is reddened. B. Pt is continuously drooling saliva. C. Pt complains of severe pain in the feet. D. Pt's BP is 150/82.

B. Pt is continuously drooling saliva.

The nurse is admitting a patient who has a neck fracture at the C6 level to the ICU. Which assessment findings indicate neurogenic shock? A. Involuntary and spastic movement. B. Hypotension and warm extremities. C. Hyperactive reflexes below the injury. D. Lack of sensation or movement below the injury.

B. Hypotension and warm extremities.

The nurse will explain to the patient who has a T2 spinal cord transection injury that: A. Use of the shoulders will be limited. B. Function of both arms should be retained. C. Total loss of respiratory function may occur. D. Tachycardia is common with this type of injury.

B. Function of both arms should be retained.

Which nursing action has the highest priority for a patient who was admitted 16 hours earlier with a C5 SCI? A. Cardiac monitoring for bradycardia. B. Assessment of respiratory rate and effort. C. Administration of low-molecular-weight heparin. D. Application of pneumatic compression devices to legs.

B. Assessment of respiratory rate and effort.

A patient who had a C7 SCI one month ago has a weak cough effort and crackles. The initial intervention by the nurse should be to: A. Suction the patient's nasopharynx. B. Notify the patient's health care provider. C. Push upward on the epigastric area as the patient coughs. D. Suggest the patient receive a tracheostomy tube.

C. Push upward on the epigastric area as the patient coughs.

Which of these nursing actions for a patient with GBS is appropriate for the nurse to delegate to an experienced UAP? A. Nasogastric tube feeding Q4hr. B. Artificial tear administration Q2hr. C. Assessment for bladder distention Q2hr. D. Passive ROM to extremities Q4hr.

D. Passive ROM to extremities Q4hr.

Nursing priorities for DKA:

1. ABC's (protecting airway?) 2. VS (electrolyte imbalance) 3. Treat fluid and electrolyte imbalances (severe dehydration, hyperglycemia, hyperkalemia)

A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is appropriate? A. "Do you have a history of IV drug use?" B. "Do you use any OTC drugs?" C. "Have you used corticosteroids for any reason?" D. "Have you recently traveled to a foreign country?"

B. "Do you use any OTC drugs?"

Which focused data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? A. Hemoglobin B. Temperature C. Activity level D. Albumin level

D. Albumin level

A serum potassium level of 3.2 is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take? A. Withhold both drugs. B. Administer both drugs. C. Administer the furosemide. D. Administer the spironolactone.

D. Administer the spironolactone. ** Lasix is non-K sparing, spironolactone is K-sparing. Pt has low K levels, so we do not want to further deplete.

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? A. The patient is alert and oriented. B. The patient denies nausea or anorexia. C. The patient's bilirubin level decreases. D. The patient has at least one stool daily.

A. The patient is alert and oriented. ** Lactulose is removing the ammonia, ammonia is a toxin that can cause hepatic encephalopathy.

To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor: A. bilirubin levels B. ammonia levels C. potassium levels D. prothrombin time

B. ammonia levels

A patient with cirrhosis has ascites and 4+ pitting edema of the feet and legs. Which nursing action will be included in the plan of care? A. Restrict daily dietary protein intake. B. Reposition the patient every 4 hours. C. Perform passive ROM twice daily. D. Place the patient on a pressure-relief mattress.

D. Place the patient on a pressure-relief mattress.

Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a patient who has acute pancreatitis? A. Calcium B. Bilirubin C. Amylase D. Potassium

C. Amylase

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis? A. Nausea and vomiting B. Hypotonic bowel sounds C. Muscle twitching and finger numbness D. Upper abdominal tenderness and guarding

C. Muscle twitching and finger numbness

The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase): A. at bedtime B. with meals C. in the morning D. for abdominal pain

B. with meals

A patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator to the nurse that the medication has been effective? A. The patient reports no chest pain B. Blood pressure is 140/90. C. Stools test negative for occult blood. D. The apical pulse rate is 68 bpm.

C. Stools test negative for occult blood.

When taking the BP on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next? A. Ask the pt about any arm pain. B. Retake the pt's BP. C. Check the calcium level in the chart. D. Notify the heath care provider immediately.

C. Check the calcium level in the chart.

A patient with acute pancreatitis is NPO and has a NG tube to suction. Which information by the nurse indicates that these therapies have been effective? A. Bowel sounds are present. B. Grey Turner sign resolves. C. Electrolyte levels are normal. D. Abdominal pain is decreased.

D. Abdominal pain is decreased.

A patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient in: A. perform leg exercises Q1hr while awake. B. work with physical therapy. C. turn, cough, and deep breathe every 2 hours. D. choose preferred low-fat foods from the menu.

C. turn, cough, and deep breathe every 2 hours.

How is the severity of a TBI determined? (4)

1. GCS score immediately following resuscitation 2. Presence (or absence) of brain damage seen on the CT/MRI following the trauma 3. Estimation of the force of the trauma 4. S/S presenting

What patient history should we obtain r/t a TBI? (3)

1. Info about the event: What happened? When? Where? How? 2. Info after the event: LOC? Mental state? Seizure activity? 3. Medical History (comorbidities): Seizures, CV, BP, immunocompromised, SUDs, sensory deficits

TBI + Neuro Assessment (6)

1. LOC 2. GCS 3. PERRLA 4. Signs of increased ICP 5. HA 6. Seizures

TBI + Respiratory Assessment (3)

1. Breathing pattern + RR (Cheyne-Stokes/apnea?) 2. Hypoxemia? (PaO2); Hyper/hypocarbia? (PaCO2) 3. Effectively managing airway?

TBI + CV Assessment (4)

Monitor for autoregulation impairment: 1. BP 2. HR 3. Pulses 4. Temperature

TBI + MS Assessment (4)

1. Mobility (bilateral motor responses) 2. Brainstem/cerebellar injury: ataxia? weakness? rigidity? 3. Alteration in sensorium? 4. Posturing: Decerebrate? Decorticate?

Treat all TBI patients are as though they have a ________ injury until proven otherwise.

SCI (transport with cervical collar and spine board; spinal precautions)

Spinal Precautions:

1. Bedrest 2. No neck flexion with pillow or roll 3. No thoracic or lumbar flexion 4. Cervical collar 5. Log roll for repositioning

Subtle changes in what three things can help to determine neurologic deterioration?

1. BP 2. Consciousness 3. Pupillary reaction to light

The most important variable to assess with any TBI is ____ because this is typically the first sign of neurologic deterioration.

Level of Consciousness: decreased in arousal, increased sleepiness, restlessness, combativeness

Early indicators of a change in LOC include (2):

1. Behavioral changes (restlessness, irritability) 2. Disorientation

S/S of Autoregulation Impairment (3):

1. Hypotension (or HTN per book) 2. Decreased pulses 3. Dysrhythmias

Interventions for a TBI (5):

1. ICP monitoring/reduction 2. IVF 3. BP Meds 4. O2 5. Seizure Precautions 6. Intubation/MV if necessary

What is Cushing Triad and what is it a classic but very late sign of?

Late sign of increased ICP/ possible heriation. 1. Irregular respiratory rate 2. Widened pulse pressure 3. Bradycardia

Treatment for Cerebral Edema:

MANNITOL (osmotic diuretic)

Interventions r/t Mannitol (3):

1. Filtered tubing 2. Assess for weakness + edema 3. Labs: RFP, Osmolarity, electrolytes

Treatment for Diabetes Insipidus (2):

1. IVF to maintain hydration 2. Vasopressin to increase ADH

Treatment for SIADH (3):

1. Hypertonic saline (3% NaCl) 2. Vasopressin antagonists to promote water excretion and retain Na (ONLY WITH LOW NA) 3. Diuretics (ONLY WITH NORMAL NA LEVELS)

Interventions for a Decompressive Craniectomy (2):

1. Strict positioning orders 2. Helmet when OOB

Indicators of a poor prognosis with TBI (6):

1. Hypoxia 2. Fever 3. Blown of fixed pupils 4. CPP <70 5. 2-point change in GCS 6. Cushing Triad

An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via ambulance. Which action should the nurse take first? A. Assess LOC. B. Obtain VS. C. Administer O2. D. Evaluate respiratory status.

D. Evaluate respiratory status.

A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client's teaching? A. "Stroke the inner aspect of your thigh to initiate voiding." B. "Use a clean technique for intermittent catheterization." C. "Implement digital anal stimulation when your bladder is full." D. "Tighten your abdominal muscles to stimulate urine flow."

D. "Tighten your abdominal muscles to stimulate urine flow."

The nurse is preparing a client for a Tensilon test. What action by the nurse is most important? A. Administering anxiolytics B. Having a ventilator nearby C. Obtaining atropine sulfate D. Sedating the client

C. Obtaining atropine sulfate

A nurse obtains a client's health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this client? A. "I drink two glasses of red wine each week." B. "I take a lot of Tylenol for my arthritis pain." C. "I have a cousin who died of liver cancer." D. "I got a hepatitis vaccine before traveling."

B. "I take a lot of Tylenol for my arthritis pain." ** do not exceed 4000 mg/day

After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? A. "I cannot drink alcohol at all anymore." B. "I need to avoid protein in my diet." C. "I should not take OTC medications." D. "I should eat small, frequent, balanced meals."

B. "I need to avoid protein in my diet."

A nurse is caring for a 47 year-old patient who is 2 hours post laparoscopic cholecystectomy (and otherwise healthy). The patient is recovering well. The nurse should expect to: SATA A. Encourage the patient to ambulate in order to decrease pain associated with CO2 insufflation. B. Be discharged to a skilled nursing facility tomorrow. C. Be discharged home today. D. Tolerate PO medication for pain relief. E. Need increasing amounts of oxygen. F. Educate the patient to eliminate all fat from her diet.

A, C, D

Exam II Flashcards

(83 cards)